Images in clinical medicine. Psoriasis flare from Koebner's phenomenon after acupuncture.

n engl j med 368;17 nejm.org april 25, 2013 1635 A73-year-old man who had had plaque psoriasis for more than 20 years on the arms, legs, and scalp presented for consultation on a new rash. He had been using topical steroid creams and shampoos to control occasional psoriatic flares. The patient had undergone acupuncture for lower back pain 2 months before presentation, and shortly thereafter new guttate psoriasis developed in the areas directly punctured with needles. Skin examination revealed multiple discrete, erythematous, scaly, indurated papules on the lower back and buttocks, areas which had not previously been affected. He reported no upper respiratory symptoms. Irritation and infection are rare complications of acupuncture when performed to established standards. Needling of the skin can produce trauma that is sufficient to cause Koebner’s phenomenon and subsequent guttate psoriatic flare. The patient declined systemic therapy, and clobetasol cream was prescribed for application to affected areas. The psoriatic flare of the lower back and buttocks resolved after treatment with the clobetasol cream. Given the patient’s reaction, he was advised to discontinue acupuncture.